Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services

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DHS-2 Rev. 10-14

Instructions Page 1 of 4

RHODE ISLAND DEPARTMENT OF HUMAN SERVICES

APPLICATION FOR ASSISTANCE (DHS-2)

General Instructions for Completing this

Application

You can ask for help in completing this form. You can ask for the form and notices to be translated. If you have a disability or condition that makes it hard

for you to understand or answer questions on this application, we can help. Please let us know by speaking with a DHS representative or calling the DHS

Information Line at 462-5300.

If you would like to apply for Medicaid affordable health care coverage, you must complete a different application.

Health care coverage is available for families with income up to 133% of the Federal Poverty Level (FPL), children and pregnant women with income up to

250% of the FPL and childless adults age 19 to 64 with income up to 133% FPL. Adults with disabilities who do not need long term services and supports

or adults who do not meet criteria for a disability determination or have too much money in the bank may apply for affordable health care coverage. You

can apply for health care coverage in the following ways:

•

online at

•

calling the HRSI Contact Center at 1-855-840-4774

•

in-person, at a local DHS Office

•

mailing in a paper application. Applications can be found online at

under “What's New?" or "Forms and Applications”

Answer All Questions

If you answer all the questions on the assistance application, we can determine if you are eligible for ALL programs. The program symbols below will appear

next to each of the questions on the application. These symbols tell you which questions you must answer for each program. If the symbol for the program(s)

you are applying for appears next to the question, you must answer that question.

RI Works (RIW) Cash Assistance: The RIW Program gives cash assistance for a limited number of months to families in need of support, as well as

those who are unable to work, or in training or looking for a job. Applicants for RIW must be responsible for the support and care of a child under age 18, or

between 18 and 19 if enrolled full-time in and expected to complete secondary school prior to their 19th birthday. RIW cash assistance requires an interview

with an eligibility worker and a meeting with a Social Caseworker to complete an employment plan.

Supplemental Nutrition Assistance Program (SNAP): The SNAP program helps low income households buy the food needed to stay healthy. You

may be able to get SNAP benefits within 7 days if your household has little or no income, your rent or housing costs are higher than your income/resources,

or if you are a seasonal or migrant farmworker. All other households will receive an eligibility determination within 30 days of the application filing date.

You will need to participate in an interview over the telephone or in the office before you can be granted SNAP benefits.

Medicaid: Long Term Services and Supports: Medicaid Long Services and Supports (LTSS) are available for individuals age 65 and older and

for individuals with disabilities. You must meet both the financial and functional/clinical “level of care” need to qualify for eligible LTSS. The types of

services available include Nursing Home Care or Home and Community Based Services. Services include but are not limited to homemaker/CNA services,

Environmental modifications, Case Management, Assisted Living, Personal care services (self-directed care), respite, minor home modifications and shared

living/RIte at Home. The type of services you receive depends on your level of care needs.

Medicaid/Health Coverage for Aged, Blind and Disabled (ABD) and Working Adults with Disabilities/Sherlock Plan: To qualify for Medicaid

under the ABD category, an individual or member of a couple must be age 65 years or older, blind or disabled. Your income, resources and health needs will

determine if you are eligible. Individuals who receive Retirement, Survivors and Disability Insurance (RSDI) or Supplemental Security Income (SSI) based

on disability meet the criteria for disability. For all others, a disability review must be completed and determination of disability must be made before

eligibility for Medicaid based on disability can be established. Medicaid for Working People with Disabilities Program/Sherlock Plan: People eligible

under this category are entitled to the full scope of Medicaid benefits, home and community-based services, and services needed to facilitate and/or maintain

employment. To be found eligible for this program, a person must be at least eighteen (18) years of age, meet the Medicaid requirements for eligibility based

on a disability, have proof of active, paid employment and meet the income and resources standards.

General Public Assistance (GPA) Program: GPA is available for adults age 19-64 years of age who have very limited income and resources and

have an illness or medical condition that keeps them from working. Sometimes, adults who have a current pending application for Supplemental Security

Income (SSI) may be determined eligible for GPA benefits. A determination for Medicaid affordable care coverage must be completed prior to a

determination of eligibility under a disability. GPA applicants can apply for affordable healthcare coverage by completing the UHIP LF-1, Application for

Health Care Coverage or by applying online at

Child Care Assistance Program (CCAP): Child Care Assistance is only available to families with earnings up to 180% of the federal poverty

level for your family size and only available to cover hours of employment or short-term training. Families may be required to pay a co-payment based on

their family size, income level, and number of children. For parents that participate in the Rhode Island Works Program, there is no income limit for child

care because if a family is eligible for RI Works, they already meet the income requirements for the Child Care Assistance Program (CCAP). Prior to

enrollment, RI Works applicants or participants who are not employed must discuss child care options with a Social Worker as part of the assessment

process and the development of the employment plan. For families not participating in the RI Works Program, eligibility for child care assistance is based

on working at least 20 hours per week at or above Rhode Island's minimum wage.